Provider Demographics
NPI:1952418535
Name:MARYLAND SPINE CENTER CHARTERED
Entity type:Organization
Organization Name:MARYLAND SPINE CENTER CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TITLE
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS, II
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-659-2802
Mailing Address - Street 1:PO BOX 418375
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-8375
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 ST PAUL PLACE
Practice Address - Street 2:SPINE CENTER, LOWER LEVEL
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202
Practice Address - Country:US
Practice Address - Phone:410-539-3434
Practice Address - Fax:410-366-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF 482OtherBLUE CHOICE
MD374002100Medicaid
LZ51OtherBC / BS OF MD
MD374002100Medicaid